Isometric Exercise for Tendinopathy

23/6/2015

Tendon pain is the most common gradual-onset, overloading injury. Mechanotherapy / exercise is the most beneficial treatment option.

Eccentric exercises have been commonly prescribed over the last decade, following the pain-provoking Alfredson programme of 3 x 15 reps, twice/day. It sometimes works very well.

The last few years I’ve favoured isometric exercise as an initial treatment - partly because of personal experience with Achilles, patellar, and lateral elbow tendon issues, & recommendation from Jill Cook & Craig Purdham at the AIS.

New research adds some support to isometric exercise as a treatment for tendinopathy, concluding it reduces tendon pain and improves strength. The authors delve in to all the “hows” & “whys” of how it works in their discussion, and to be honest it’s a bit technical for my understanding.

The research protocol uses 5 reps of a 45 second contraction, at a 70% effort. I prefer a more gentle contraction of 50% effort, but a longer hold of at least a minute, and I like a larger total volume of at least 10 minutes/day. Obviously it’s hard to define what the perfect dosage is for exercise, & volume could be adjusted depending on results.

I like isometrics because:

you don’t need any equipment / you can do them anywhere
they're easily done for all the common tendinopathies
they can be started straight away, even in the most painful cases
they work well

40 Comments

Robert

14/5/2016 02:14:07 pm

I was looking to incorporate isometrics in rehab for my brachialis issue from bouldering/rock climbing. I was wondering about suggestions for sets/repetitions and frequency, I wanted to try isometric pullups (hanging at 90 degrees at the elbow), along with static stretches.

Fergus

14/5/2016 07:41:43 pm

I wouldn't recommend static stretching. In most cases it seems to be aggravating.

A number of different isometric protocols have been studied. 5 x 45secs / day. 3 x 30 secs, 2/day. I like as high volume as possible: 10 x 60secs, spread out hourly. I thunk it's total time under tension that provides the benefit. And "time under tension" is the variable to progress as pain improves.

For me, it's not a set recipe of sets x reps, but what I can get the patient to actually do. Doing something is the thing that makes the difference.

16/5/2016 02:39:45 pm

I feel 3x30 twice a day is most suitable since I'm doing static holds with my whole bodyweight. Do you think I need to find a way to lessen the load on my arms somehow and do longer holds?

16/5/2016 02:48:20 pm

And also, I would appreciate input on whether or not there's need for a warmup for this sort of rehabilitative isometrics, and your opinion on rest periods between sets.

Fergus link

16/5/2016 05:25:31 pm

Warm-up not required. 30sec hold / 30sec rest / repeat x 3.

I would lessen the load if it was > 4/10 pain to hold it, or if it stayed sore after.

17/5/2016 08:43:11 am

Thank you so much for the help! So far it feels good, and I am looking forward to seeing the long term effects.

Layya Halawi

21/4/2018 10:58:54 pm

Hello Robert,
Can you kindly update us on your condition and whether the pullups isometrics 3x a day worked well for you? How long did it take to fully heal?

Anita Stack

4/6/2016 05:13:55 pm

Hi I have recently ben told I have Tendinopathy of the Gluteus Medius. I have just read your description of Isometric exercises being a good way to start to help the problem. Can you give me some examples of what I could do. I have visited a local physio who gave me one exercise but wants me re visit to get the next one which is costly and time consuming for me.
Kind Regards
Anita

5/6/2016 10:34:52 am

Hi Anita,

I'd try 3 x 30sec holds, 2/day of a "hip hitch" exercise.

Search "hip hitch" on Youtube. Here's an example: https://www.youtube.com/watch?v=nUlvHH_rFo4

Up and hold 30 seconds, rather than up/down in the video.

Kind regards, Fergus.

steve

28/9/2016 06:31:38 pm

Really eye-opening...
I try your regime for my proximal biceps tendon for already one week with 5x60sec daily (with static body row) but it hurts during and after the exercise.
Do I have to lower the weight or change the exercise??

Greetings from Germany

28/9/2016 07:59:40 pm

G'day Steve,

If your diagnosis is a long head of biceps tendinopathy, I like an isometric anterior straight-arm fly, with your palm facing up (not bending the elbow, but lifting the whole arm straight up fwds). Pushing against a table is convenient.

As far as sets/reps/effort/pain I'd start with 3 x 30 second holds, 2/day, with an effort that elicits < 4/10 pain. This might be 50-70% as hard as you can push. If it stays sore after the exercise, then you've pushed too hard. Another commonly prescribed regime is 5 x 45 seconds. I would expect an improvement in pain on the first day, so if it's not any better then you need to modify something.

Having said that, LHBs are stubborn, and I also like you to position up & back with your scapula (stabilise it out of the way).

It's a diagnosis I'd respect. Try and not aggravate it in the gym with your training.

Kind regards,

Fergus.

3/11/2016 07:54:48 am

Thank you so much for you reply...
I will try it...

Do you think i can work around the injury in the gym??
What about exercises like deadlifts with straps?

Kind regards

3/11/2016 08:36:42 am

Steve, yes I would work around it rather than push through it. That may mean dropping weight 25% or swapping for an exercise with different grip. Anything that doesn't hurt.

Layya

21/4/2018 11:15:55 pm

Thanks for all these tips. For the "isometric anterior straight-arm fly", I need to have my arms straight at 90 degrees to my body or lower or it doesn't matter?
Condition: anterior shoulder pain (possibly LHBT).

21/4/2018 11:05:06 pm

Hi Steve,

Did the isometric arm flies workout? How long did it take your tendon to heal?

Margaret

28/12/2016 04:30:43 am

Hi. Appreciate your blog very much. Female age 60, with "medium" grade muscle-tendon tear. Therapist has me doing buttock squeezes, bridges, and sit-to-stand exercises mostly. 10 reps twice a day. Pain and walking only ever so slightly better. Still hurts standing on one leg, and walking still hurts, also have lost quite a bit of range of motion in my hip. These exercises seem to be about all I can tolerate but I don't see much improvement after two months. Also wall presses, but I do those while standing on good side which I think activates glute med in unaffected side only. Not sure why therapist has me do that. What else can I do to improve?

FERGUS

28/12/2016 09:06:40 am

Hi Margaret,

You haven't said which bit of you is sore - but I'll guess you've got a glute med tendinopathy (sore on the side of your hip?).

The exercises you're doing sound like good general strength exercises. But I agree if you're not improving you need to change something.

Key points I'd emphasise:
•Sleep with a pillow between your legs.
•Try and walk a similar number of steps every day, starting with 25% less than whatever your "normal" exercise volume would be, and build up gradually.
•Losing weight quite often helps a lot.
•I like isometric exercise - so for glute med: stand on the sore leg (hang onto something for balance) and shift your bum sideways, away to the other side, and hold that position for at least 30 secs. (So if the sore side is the left - you stand on the left leg and shift your bum sideways to the right - which uses the muscles on the side of the left hip).
• When you're walking imagine you're straddling a rope at the height of your knees and don't let them touch it (keep your knees apart)

Happy to clarify further : )

28/12/2016 01:15:03 pm

Oh ,so sorry ! Yes, gluteus medius tear, at point of tendon I assume. Unfortunately, misdiagnosed for over a year as lower back pain and hip bursitis, so I was doing my normal walking exercise until I couldn't stand it any more. Gave up my beloved walks months ago as the pain was so bad, but I should start back gently. I like your suggestions of isometric exercises, and the pillow between leg which probably helps lessen compression on the tendon (?) or lessens pulling on tendon (?) so I will give them a go. I miss walking so much. And interestingly, I weigh 10 -15 lbs more than I should. It makes sense that extra weight isn't good in this situation, so clearly this is motivation to lose weight. Appreciate the feedback greatly. Thank you!

Liv abbott

2/1/2017 10:12:46 pm

Could this same protocol be used for obturator internus pain and tedinopathy? Thank you

3/1/2017 07:52:13 am

Hi Liv, Absolutely.

I prefer not to get too caught up in the anatomical minutiae. The muscle you're talking about has a similar action to glute med, so I presume you've got the same lateral hip pain?

Find the exercise that loads your sore muscle and hold the effort for 5 x 45secs/day.

Kind regards,

Fergus.

3/1/2017 08:56:20 am

Thank you! How long does it 'normally' take for pain to resolve? So I can manage my expectations ha

3/1/2017 09:00:43 am

I would it expect isometrics to noticeably give you pain relief on the first day. Definitely much better within a couple of weeks, depending on how diligent you are at getting it done. If it's not "working" I'd change the direction of force or re-look at the diagnosis.

12/5/2017 10:57:29 pm

I had tendinopathy in one of my rotator cuffs and long head of the bisceps in my left shoulder. After months of physio treatment my physiotherapist set me up with one of the leading sports medicine doctors in toronto to get prp injections. That was about 5 or 6 years ago. It worked great. I am painfree and able to do everything i use to do. That was my experience.

Steve

9/7/2017 01:27:45 am

Hi
Thank you for your insightful advise on gluteal medius tendinopathy. I was diagnosed with left gluteal media tendinpathy 6 weeks ago by my Physiotherapist. He gave me isometric dynamic hip hitch to do . It is now improving but still sore especially when I sit for a while. Any idea what else I can do to get better soon?
Steve

9/7/2017 12:16:44 pm

Hi Steve,

I like a hip hitch - isometric holds of 3 x 30 secs, 2/day. Also general leg strengthening, like double leg squats, progressing to single leg. Ice and Ibuprofen. Try and even out the number of steps/day through the week - so no big days or quiet days. I'd like to see some improvement before 6 weeks, but it does take months before it's 100%, so stay patient.

Kind regards,

Fergus.

Justin's D.

4/8/2017 09:40:44 am

Hi,

I recently was diagnosed with patellar tendinitis in my right knee. I read your article and one of Eboni Rios Snd Jill Cooks. I see the emphasis on isometric exercises. Can you recommend some therapy exercises I can do to be rid of the pain and get me back into the gym. Much appreciated!

Justin

Ferg

4/8/2017 10:45:49 am

Hi Justin,

For patellar tendinopathy I like to start with an isometric single-leg squat > stand on the sore leg > hang on to something for balance > lower to the point of soreness (stay chest up, so you're bending the knee to squat) > hold there for 45 seconds > repeat x 10/day.

Tim

16/8/2017 07:29:13 am

Hello,

Thank you for taking the time to review my case. I have right elbow pain which under load is worse when pronated.
After weeks of rest and avoiding some exercises I went for an mri.

Distal bicep and brachioradialis tendinosis was the report. I have been doing eccentric curls for a couple of months with very minimal improvement.
My physio has me trying some form of shock therapy last week and will use PRP if that fails to help.
Keen and appreciative to hear what isometric exercises you may recommend.

Tim

16/8/2017 10:28:21 am

G'day Tim,

I'd recommend isometrics > elbow at 90° > palm down (pronation) > isometric supination (twist palm up but don't let it move > block it with the other hand) > push as hard as you can hold the effort for 45 secs. 3 x 45 second efforts, 3/day.

Be aware that upper limb tendons are smaller and have less capacity than lower limb tendons, so are easier to "overload" and aggravate. So often stepping back the intensity of the loading regime works well. I like a higher volume of lower intensity contraction.

Kind regards,

Fergus.

Rich

29/1/2018 01:59:08 pm

hi,

i have been diagnosed with calcific tendonitis (distal insertion of triceps) at the elbows, i have been working around the pain in the gym and can train pain free, but seem to get more pain from doing pulling movements and deadlifts, can you recommend and exercises please?

i want to keep training - is this ok?

thanks!!

30/1/2018 02:48:43 pm

Hi Rich,

I'd suggest trying an isometric version of whichever exercise is painful. Hold still at the painful point in the movement, with a weight that you can hold for 45 seconds (ie, it will be a lighter weight - if it's too heavy you won't be able to hold it for 45). Try 3 reps each time you're training. And don't do your normal version of that exercise if it's painful. Find a pain-free alternative way of working the same muscle group.

Kind regards,

Ferg.

30/1/2018 03:48:54 pm

thanks for the reply, if it hurts after i do the exercises is that ok?
or should i go lighter?
i normally get then pain a few hours later or at night.

30/1/2018 04:07:48 pm

I would expect some soreness during the hold, but not immediately after. Soreness later in the day means something else is overloading it, and I'd look to modify whatever other activity it is that's aggravating.

1/2/2018 11:52:05 am

Hi Fregus,

i did isometric holds today (tricep pushdowns - holding mid range), its a little sore after but nothing too bad, is that ok or do i need to go lighter?

thanks

1/2/2018 12:36:29 pm

I'd look for a level of resistance that is sore to hold, but not sore after.

Jon

14/10/2018 02:00:38 am

I had a sports hernia that was repaired earlier this year along with adductor tendinopathy. My abdominal symptoms were fixed with the surgery but unfortunately the adductor did not. I then had an adductor tenotomy which definitely cut away a lot of scarred tendon tissue but unfortunately I still get discomfort at the pubic tubercle region right where the adductor tendon inserts with adduction movements. I had the adductor surgery in May. I'm trying to do isometric ball between my knee holds? Is this the correct protocol?

DEBBY Bosch

26/6/2020 03:34:55 am

I’m 5 months THR post op and have chronic gluteus medius tendinopathy. Is it normal not to be able to walk for more than 30 steps without pain? I am doing isometric exercises for just over two weeks with no improvement yet. I can’t get past 25 second holds. As soon as I do, I am back to where I started.

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